Nursing Diagnosis Impaired Skin/Tissue Integrity related to mechanical trauma of surgical removal of skin and subcutaneou s tissue secondary to Cesarean section
Backgrou nd Study Skin is the body’s first line of defense against foreign materials that can be considered as injuring agents. Once the skin is disrupted, this will put Assessment a person at Subjective: risk since it “Mayda ak may samad kay become a gin Cesarean good ak paganak,” medium for verbalized by bacterial the client. growth. Objective: Cesarean Destruction section, of skin layers like any Desruption of other tissue layers. surgical (+)Redness procedures on the , includes incision site. invasion of (+)Swelling the inside on the body, incision site specifically
INFEREN CE Emergenc y CS
Abdomina l incision and Uterine incision
Alteration s of the Skin
Goals and Objectives GOAL: After 3 days of nursing interventions, the patient will be able to display timely healing of skin lesions/ wounds without complication. OBJECTIVES : After 8 hours of nursing interventions, the patient will be able to: Participate in prevention measures and treatment program Maintain physical well-being. Ability to manage situation. •
•
•
Inte Interv rven enti tion ons s
Rati Ration onal ale e
Independent Establish rapport
Perform bedside care
To gain trust with the client To enhance patient’s self esteem and to provide comfort to the patient
Insp Inspec ectt skin skin on dai daily bas basis and obseve for To determine changes and unusual ties unusualities and report it to physician for prompt treatment. Keep Keep the the area clean, clean, caref carefull ully y This will assist dress wound, body’s natural support support incison, incison, prevent infection process of
Eval Evalua uati tion on
Goal met as evidenced by the patient has able to display timely healing of skin lesions/ wounds without complication .
the skin and subcutaneo us area. th
(NANDA 9 edition.pp 461-465) (MedSurgical Nursing, Black and Hawks 8th Edition pp 952-954)
repair Encourage client to demons demonstra trate te good skin hygi hygie ene, ne, e.g. e.g.,, wash thoroughl thoroughly y and pat dry care carefu full lly y afte afterr teaching.
DEPENDENT Medication such as antibiotics
Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin
To prevent COLLABORATIV post operative E wound Provide optimum complication nutrition such as increased protein intake. To provide a positive nitrogen balance to aid in healing. (NANDA 9th edition pp 461-465) (Med-Surgical Nursing, Black and Hawks 8 th
Edition pp 952-954)
Nursing Diagnosi s Acute pain related related to abdomina l inci incisi sion on secondary to surgery. Subjecti ve cues: “Masakit pa an tinahian han han ak tiyan nan nakukuria n ak pagkiwa” as
Backgroun d Study
INFERENC E
Goals and Objectives
Pain is defi define ned d as unpleasant sensory and emotional experience arising from actual actual or potential tissue damage damage or described in terms of such damage. (Internation al Association for the
Emergency CS
GOAL: At the end of my nursing intervention of 8 hours duty, the patient will be able to report pain is relieved or controlled.
Abdominal and uterine incision
Tissue trauma
OBJECTIVES : By the of 1hour of my nursing Prostagland intervention, the in release+ client will: Uterine Contraction Report pain + Loss of intensity Anesthetic from 4 to 6 Effect will decrease at •
Interventions
Rationale
Independent Establish rapport to the patient
Monitor Vital signs
Perform bedside care
To easily gain cooperation cooperation form the patient To have baseline data and for comparison for future data To enhance patient’s self esteem and to provide comfort to
Evaluatio n
Goal met as evidenced by the patient has able to manage pain relieve and controlled from 4to 6 to 2-3 on the pain rating scale.
verbalized by the patient.
Objectiv e cues: Temp:
38.4 °C 88 PR: bpm 24 RR: cpm BP: 130/90 mm Hg Rated pain as 4 to 6 out of 0 to 10 pain scale. Pain increa ses when moves vigoro usly Incision site:
Study Pain);
(Nurse’s Pocket Guide)
of
2 to 3 from 0 to 10 pain scale.
Sensation of Pain •
Elevated Vital Signs
•
Participate in demonstrati ng techniques to relieve pain Have ability to manage situation.
the patient Observe and document location, severity and character of pain.
Promote bedrest, allowing patient to assume position of comfort Control environment temperature
By getting the following information, we are asssitting in differentiating cause of pain and providing information about disease progression/resoluti on, development of complications complications and effective interventions. Bedrest in lowfowler’s posiiton reduces intraabdominal pressure.
Cool surrounding aids in minimizing dermal discomfort.
Employ non pharmacologic pain distraction To prevent such as: Music Music therap therapy, y, dependecy on medication for pain Imagery,etc
DEPENDENT Medication such as
Wound: dry, no discharge s noted Dressing and plaster were clean clean and fully covered the incision site No foul odor noted on the site.
NSAID’s
Relieves pain immediately.
(NANDA 9th edition pp 461-465)
